R E S E A R C H Open AccessQuality of life in patients aged 80 or over after ICU discharge Alexis Tabah1, Francois Philippart1,2, Jean Francois Timsit3,4, Vincent Willems1, Adrien França
Trang 1R E S E A R C H Open Access
Quality of life in patients aged 80 or over after ICU discharge
Alexis Tabah1, Francois Philippart1,2, Jean Francois Timsit3,4, Vincent Willems1, Adrien Français3, Alain Leplège5, Jean Carlet1, Cédric Bruel1, Benoit Misset1,6, Maité Garrouste-Orgeas1,2*
Abstract
Introduction: Our objective was to describe self-sufficiency and quality of life one year after intensive care unit (ICU) discharge of patients aged 80 years or over
Methods: We performed a prospective observational study in a medical-surgical ICU in a tertiary non-university hospital We included patients aged 80 or over at ICU admission in 2005 or 2006 and we recorded age, admission diagnosis, intensity of care, and severity of acute and chronic illnesses, as well as ICU, hospital, and one-year
mortality rates Self-sufficiency (Katz Index of Activities of Daily Living) was assessed at ICU admission and one year after ICU discharge Quality of life (WHO-QOL OLD and WHO-QOL BREF) was assessed one year after ICU discharge Results: Of the 115 consecutive patients aged 80 or over (18.2% of admitted patients), 106 were included Mean age was 84 ± 3 years (range, 80 to 92) Mortality was 40/106 (37%) at ICU discharge, 48/106 (45.2%) at hospital discharge, and 73/106 (68.9%) one year after ICU discharge In the 23 patients evaluated after one year,
self-sufficiency was unchanged compared to the pre-admission status Quality of life evaluations after one year showed that physical health, sensory abilities, self-sufficiency, and social participation had slightly worse ratings than the other domains, whereas social relationships, environment, and fear of death and dying had the best ratings
Compared to an age- and sex-matched sample of the general population, our cohort had better ratings for
psychological health, social relationships, and environment, less fear of death and dying, better expectations about past, present, and future activities and better intimacy (friendship and love)
Conclusions: Among patients aged 80 or over who were selected at ICU admission, 80% were self-sufficient for activities of daily living one year after ICU discharge, 31% were alive, with no change in self-sufficiency and with similar quality of life to that of the general population matched on age and sex However, these results must be interpreted cautiously due to the small sample of survivors
Introduction
The human lifespan is increasing across the world as a
result of economic progress, technological advances, and
improved healthcare In 2007, it was estimated that 98
million people, or 1.5% of the world population, were
older than 80 years [1] French census data show a
steady increase in the proportion of elderly individuals
and, in 2008, 3.9 million individuals were aged 75 to
84 years and 1.4 million were older than 85 years [2]
One consequence of this increasing lifespan is that a
growing number of very elderly patients are being
admitted to the intensive care unit (ICU) Critical care seeks not only to ensure survival, but also to restore the pre-admission level of function and to return the patient
to his or her pre-admission living arrangements Elderly patients who survive a critical illness at the cost of further functional impairments may require nursing-home admission, an outcome most of them deem unde-sirable [3] Whereas self-sufficiency is an objective outcome, quality-of-life assessments provide information
on outcomes perceived by ICU survivors [4] The World Health Organization (WHO) defines quality of life as‘an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, stan-dards and concerns’ [5]
* Correspondence: mgarrouste@hpsj.fr
1 Medical-Surgical ICU, Saint Joseph Hospital Network, 185 rue Raymond
Losserand, 75014 Paris, France
© 2010 Tabah et al.; licensee BioMed Central Ltd This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
Trang 2Few data are available on quality of life in very elderly
ICU survivors compared to the general population [6-8]
One study detected no difference [8], another found
decreases in specific domains with similar overall quality
of life [6], and two studies found worse quality of life
[7,9] These discrepancies may be ascribable to
differ-ences in the tools used to assess quality of life and to
the use of tools designed for the general population that
may be inappropriate in the very old [10]
The aim of this study was to evaluate self-sufficiency
and quality of life one year after ICU discharge in
patients aged 80 years or over Quality of life was
assessed using a validated tool developed for the elderly
by the World Health Organization
Materials and methods
Setting
The study was performed at the Saint Joseph Hospital, a
460-bed tertiary-care non-university hospital for adults,
located in Paris, France The hospital provides services
in all the medical specialties and in all fields of surgery
except neurosurgery The ICU is a 10-bed medical unit
that admits about 400 patients per year (mean age, 62
years), of whom 70% have medical conditions In our
ICU, we have no predefined admission criteria Our
triage process has been described elsewhere [9]
Patients
From January 1, 2005, to December 31, 2006, we
included all patients aged 80 years or over at ICU
admission Patients who were admitted several times
during the study period had only their first stay included
in the study For each patient, the attending intensivist
completed a case-report form in a database using
data-capture software (RHEA, Outcomerea, Rosny Sous Bois,
France) The following information was recorded
pro-spectively: age and sex; admission category (medical,
scheduled surgery, or unscheduled surgery); invasive
procedures (number of arterial and/or venous central
lines, endotracheal and noninvasive ventilation, dialysis,
and tracheotomy); use of vasoactive agents and inotropic
support; and patient location prior to ICU admission
(with transfer from wards defined as being in the same
hospital or another hospital before ICU admission)
Nine reasons for ICU admission were defined
prospec-tively before the study (respiratory failure, heart failure,
renal failure, coma, multiple organ failure, chronic
obstructive pulmonary disease, monitoring, trauma, and
scheduled surgery) Co-morbidities were assessed using
the McCabe score [11] and the Knaus classification
sys-tem [12] The McCabe score distinguishes two
cate-gories of underlying diseases based on whether death is
likely to occur within five years or within one year [11]
Severity of the acute illness and organ dysfunction were
measured at ICU admission using the Simplified Acute Physiology Score (SAPS II) [13], the Logistic Organ Dys-function (LOD) score [14], and the Sepsis-Related Organ Assessment (SOFA) [15] Withholding and withdrawal decisions, which were made according to the recom-mendations of the Francophone Society for Critical Care (SRLF) [16], were recorded; as well as lengths of the stays in the ICU and acute-care hospital and vital status
at ICU and hospital discharge
Quality of life
Information on prior self-sufficiency was obtained from the patient or family members, either at admission or within the first few days after admission, according to standard practice in our unit Self-sufficiency was evalu-ated using the modified Katz Index of Activities of Daily Living (ADL), which assesses the ability to perform six basic daily activities (bathing, dressing, toileting, trans-ferring, continence, and feeding) on a seven-point scale where zero indicates complete dependence and six com-plete independence [17]
Long-term quality of life was assessed using the WHOQOL-BREF and WHOQOL-OLD questionnaires developed by the World Health Organization (WHO) [18,19] The WHOQOL-BREF, which is the abbreviated version of the WHOQOL-100 [19], is a cross-culturally developed and validated questionnaire that can be used
in specific cultural settings to collect data suitable for subsequent comparison across cultures It has 26 items that cover four domains: physical health, psychological health, social relationships, and environment It also measures the individual’s perceptions of quality of life and health via two items (’How would you rate your quality of life?’ and ‘How satisfied are you with your health?’), each rated from 1 (very poor/dissatisfied) to 5 (very good/satisfied) The WHOQOL-OLD was devel-oped as an add-on module that can be used with other WHOQOL instruments to specifically address important facets of quality of life in older adults [18] It has 24 items that cover six facets (sensory abilities; autonomy; past, present, and future activities; social participation; death and dying; and intimacy) The WHOQOL-BREF questionnaire is available on the web [20] and from national WHO field centers Domain scores are calcu-lated from the items then converted to an overall per-centile scale that ranges from very poor (0%) to very good (100%)
Follow-up measures
Outcomes one year after ICU discharge were assessed over the phone Patients who failed to answer the first call were called again on different days, for a total of four calls When we were unable to contact the patient
by phone, we sought vital status information by calling
Trang 3the primary care physician and by looking for a death
certificate at the appropriate registry office (or consulate
if the patient was not French) The Katz Index and the
WHOQOL-OLD and WHOQOL-BREF questionnaires
were completed during a telephone interview conducted
by one of us (AT) Because quality of life is a subjective
personal concept that cannot be readily evaluated by
relatives, only the patients completed the quality-of-life
questionnaires In contrast, relatives were asked for
information on self-sufficiency that could not be
obtained from the patients The institutional review
board waived requirement for written informed consent
at ICU admission Each patient received information
about their inclusion in the study at ICU discharge and
at the beginning of the phone call, and then asked to
consent to the interview
Statistical analysis
Quantitative data are reported as mean ± SD if normally
distributed and as median (interquartile range (IQR))
otherwise Qualitative data are reported as n (%)
WHO-QOL scores were calculated using the files created in
SPSS by the WHO The control group was a random
sample of the general population matched on age and
sex to our patients and derived from the sample used to
validate the French version of the WHOQOL-OLD
Comparisons of self-sufficiency before and after the ICU
stay and comparisons of WHOQOL scores after the
ICU stay in our patients and in the general population
were done using the Wilcoxon test for paired data
Sta-tistical analyses were performed using SAS software
(SAS 9.1, SAS Institute, Cary, NC, USA)
Results
Patients
During the two-year study period, among the 630
conse-cutive admissions to our ICU, 115 (18.2%) were for
patients aged 80 years or over (mean age, 84 ± 3 years;
range, 80 to 92) There were seven readmissions (one
patient readmitted twice and five patients readmitted
once each, of whom two were alive after one year and
completed our evaluation) We excluded two patients
with missing data, which left 106 patients for the study
These patients had a mean age of 84 ± 2 years Among
them, 69 (65.1%) had medical conditions, 21 (19.8%)
required unscheduled surgery, and 68 (64%) were
trans-ferred from wards At admission, the mean Simplified
Acute Physiology Score was 45 ± 18.3 points and the
mean Logistic Organ Dysfunction score was 5.4 ± 3.5
points During the ICU stay, 63 (59.4%) required
ventila-tory assistance, 48 (45.3%) epinephrine/norepinephrine,
and 20 (18.9%) dialysis The median ICU stay was six
days (IQR, 3 to 11) and the median post-ICU hospital
stay was eight days (IQR, 0 to 18.5)
Of the 106 patients, 40 (37.7%) died in the ICU and 39 (36.8%) had treatment-limitation decisions, which con-sisted in withholding life-support in 22 (20.8%) patients and withdrawing life support in 20 (18.9%) patients, with three patients having both categories of decisions
Follow-up and quality of life
Of the 66 (62.2%) patients discharged alive from the ICU, eight died before hospital discharge Hospital mor-tality was 48/106 (45.2%) In addition, 25 patients died before the one-year evaluation Thus, one-year mortality was 73/106 (68.9%) Of the 33 survivors at one year, seven refused the evaluation (two were unhappy with our institution, one stated having insufficient time, two had hearing loss, and two lived at home but did not answer our multiple calls) Of the 26 remaining patients, three had dementia that precluded them from complet-ing the evaluation Self-sufficiency in these three patients was assessed by the relatives; they had ADL scores of 4, 4, and 2, respectively Quality of life was not assessed in these three patients
Quality of life was therefore assessed in 23 patients, whose mean age was 84 ± 3 years; there were 17 (73.9%) males (Table 1) Mean time from ICU discharge to eva-luation was 471 ± 121 days (25thto 75th:375 to 583), due
to difficulties experienced in locating some of the patients Mean phone call duration was 42 ± 14 minutes
As shown in Table 2, self-sufficiency was not modified after the ICU stay compared to the pre-ICU status (med-ian index values, 6 vs 6, respectively) Table 3 compared quality-of-life data in the 23 patients and in the general population matched on sex and age The survivors had significantly higher scores for psychological health; social relationships; environment; fear of death and dying; expectations about past, present, and future activities; and intimacy (friendship and love) Of the 23 patients, 18 (78%) said they would agree to another ICU admission should the need occur in the future
Discussion
We found that patients aged 80 years or over who were selected for ICU admission had no change in self-suffi-ciency one year after ICU discharge compared to the pre-admission status and had similar quality of life com-pared to age-and sex-matched individuals from the gen-eral population After one year, 78% of evaluated patients said they would agree to an ICU admission should they experience another critical illness
During the study period, patients aged 80 years or over accounted for 18.2% of all patients admitted to our ICU Patients in this age group were often refused ICU admission [9] The 18.2% admission rate was in line with data in the French ICU Outcomerea database [21] Mortality rates were high in our population: 37% at ICU
Trang 4Table 1 Main characteristics of survivors and nonsurvivors
N = 83
Survivors
N = 23 P value Age in years, mean ± SD (range) 84 ± 3 (80 to 93) 84 ± 3 (80 to 92) 0.99
Underlying disease: none or nonfatal 32 (38.6) 14 (60.9)
Underlying disease expected to cause death within five years 36 (43.4) 9 (39.1)
Underlying disease expected to cause death within one year 15 (18.1) 0
Underlying diseases according to Knaus, n (%)
Patient location before ICU admission, n (%)
Pre-ICU hospital stay,
median (IQR)
2 (0 - 6) 1 (0 - 5) 0.57
Main symptom at admission, n (%)
Septic shock and multiple organ failure 16 (19.3) 8 (34.8) 0.11
Severity of illness at admission, Mean ± SD
Intensity of care, n (%)
Length of ICU stay, days, median (IQR) 6 (3 - 12) 5 (3 - 9) 0.42 Length of post-ICU hospital stay, median (IQR) 1 (0 - 15) 17 (9 - 28) 0.0007 IQR = interquartile range; COPD = chronic obstructive pulmonary disease; SAPS II = Simplified Acute Physiologic Score [13]; LOD Logistic Organ Failure [14]; SOFA = Sepsis-Related Organ Assessment [15]
Trang 5discharge, 45.2% at hospital discharge, and 68.9% one
year after ICU discharge ICU and hospital mortality
rates have varied across studies [9,22-26], probably
because of case-mix differences In contrast, one-year
and two-year mortality rates have usually been within
the 60% to 70% range [9,22-26], in line with our results
Our relatively high ICU mortality rate was explained by
the large proportions of medical patients, patients
trans-ferred from other wards, patients with severe illness at
admission requiring a high level of care not always
pro-vided to the very elderly [27], and treatment limitations
during the ICU stay (40% of patients)
Self-sufficiency was not changed one year after ICU admission, in keeping with earlier data [6,8,9,24,25,28] Furthermore, our patients had an overall good percep-tion of their quality of life, comparable to that of the general population On both quality-of-life question-naires, mean scores on all facets were consistently within the 60% to 80% range Physical health, sensory abilities, self-sufficiency, and social participation had slightly lower ratings than the other domains Ratings were highest for social relationships, environment, and death and dying Compared to an age-and sex-matched sample of the general population, our patients had bet-ter scores for psychological health; social relationships; environment; fear of death and dying; expectations about past, present, and future activities; and intimacy (friendship and love) One hypothesis is that surviving
a life-threatening illness may offer opportunities for building psychological strength and diminishing the fear of death and dying Moreover, patients probably adjust their expectations when faced with serious ill-ness and disability, which may lead them to assign higher ratings to their quality of life The results from this study must be interpreted cautiously due to the small sample and are at variance with those of our previous study in a similar population, in which quality
of life was significantly poorer one year after ICU admission [9] In this earlier study [9], quality of life was assessed using the modified Perceived Quality of Life scale and Nottingham Health Profile Neither scale
is specifically designed for older individuals Therefore, the present study may provide a better assessment of quality of life Both studies assessed self-sufficiency using the Katz Index of ADLs, and neither found any change after the ICU stay
Table 2 Self-sufficiency before and after the ICU stay
shown by percent of patients
Nonsurvivors
N = 83
Patients alive with one-year QOL data
N = 23 Self-sufficiency1 Before ICU
admission
After one year 2 ADL = 6 55 (66.3) 19 (82.6) 17 (74)
ADL = 5 4 (4.8) 1 (4.3) 2 (8.7)
ADL = 4 8 (9.6) 3 (13) 2 (8.7)
Median ADL Score
(IQR)
6 (4 to 6) 6 (6 to 6) 6 (5 to 6)
1
Self-sufficiency was assessed using the Katz Index of Activities of Daily Living
(ADL) [17], with each activity being scored from zero (complete dependence)
to six (complete independence).
QOL = quality of life; ICU = intensive care unit
2 P = 0.80 for the comparison of self sufficiency one year after ICU discharge
and before ICU admission in the 23 alive patients, for the whole activities of
daily living
Table 3 Quality of life of the survivors compared to the general population
Study population
N = 23
General population matched on age and gender P value QOL-BREF
QOL-OLD
Past, present and future activities 69.7 ± 17.7 57.6 ± 15.7 0.02
QOL = quality of life; ICU = intensive care unit
Trang 6Most of the survivors said they would consent to ICU
admission should they experience another acute
life-threa-tening illness The preferences of elderly patients regarding
ICU admission are largely unknown in France and
else-where, although surrogate designation is known to be
pop-ular in France [29] Absence of a surrogate, or limited
ability of the surrogate to predict the patient’s wishes, may
lead to ICU refusal of elderly patients who, if conscious,
would choose ICU admission [30] In our earlier study of
patients aged 80 years or over, half the survivors said they
would agree to another ICU admission [9], whereas the
proportion was 72% in the present study Differences in
preferences of elderly patients may arise because of
varia-tions over time [31-33], most notably increased
vulnerabil-ity [34] and family burden [35] Patients who are in stable
condition one year after an ICU stay may be more likely to
express positive perceptions of their quality of life than
patients with unstable disease Furthermore, having
experienced and survived an ICU stay may lead to a more
positive opinion about ICU admission, compared to
patients with no ICU experience Patient preferences
should be taken into account when deciding whether ICU
admission is in order
This study has several limitations First, the data were
obtained at a single center and may not be applicable to
other ICUs Second, the number of patients evaluated
after one year was small This limitation is ascribable to
the usual high mortality rate in patients aged 80 years and
over who require ICU admission However, waiting one
year to perform the assessment provides a sound estimate
of post-ICU quality of life [4] Third, our patients were
selected for ICU admission based largely on
self-suffi-ciency and on the expectation that life-supporting
treat-ment would not prove futile Our data may not apply to
all patients aged 80 years and over who are admitted to
the ICU, as admission policies vary widely across countries
and within a given country Furthermore, the patients
evaluated in our study were long-term survivors and were
willing to take the time to complete our evaluation
Conclusions
In a highly selected cohort of elderly patients, among
whom fewer than one-third were alive one year after
ICU discharge, self-sufficiency was unchanged one year
after ICU admission and quality of life was comparable
to that in the same-age general population These
results invite further investigations of the preferences of
elderly patients regarding ICU admission We are
cur-rently planning such a study
Key messages
• Patients aged 80 years or over who were admitted
to the ICU were carefully selected based on
self-sufficiency
• Unlike previous studies, we found that one-year survival after ICU discharge was about 30%
• In this small sample of survivors, one year after ICU discharge, the patients were satisfied with their level of self-sufficiency and quality of life
• Quality of life, physical health, sensory abilities, self-sufficiency, and social participation had slightly lower ratings than other domains Ratings were highest for social relationships, environment, and death and dying
• Patient preferences should be taken into account when deciding whether ICU admission is in order
Abbreviations ADL: activities of daily living; COPD: chronic obstructive pulmonary disease; ICU: Intensive care unit; IQR: interquartile range; LOD: logistic organ failure; SAPS II: Simplified Acute Physiologic Score II; SOFA: Sepsis-Related Organ Assessment; SPSS: Statistical Package for the Social Sciences; SRLF: Societé de Réanimation de Langue Française; WHO: World Health Organization; WHOQOL-100: World Health Organization-Quality of Life 100; WHOQOL-BREF: World Health Organization-Quality of Life BREF; WHOQOL-OLD: World Health Organization-Quality of Life OLD.
Acknowledgements
We thank A Wolfe, MD, for helping to prepare this manuscript and E Ecosse for providing the quality-of-life data for the general population.
Author details
1 Medical-Surgical ICU, Saint Joseph Hospital Network, 185 rue Raymond Losserand, 75014 Paris, France.2Cytokines and inflammation unit, Institut Pasteur, 28 rue du Docteur Roux, 75015 Paris, France 3 INSERM U823
“Epidemiology of cancers and severe diseases”, Albert Bonniot Institute, Rond-point de la Chantourne, 38706 La Tronche Cedex.4Medical Intensive Care Unit, Albert Michallon Teaching Hospital, Joseph Fournier University, BP
217, 38043 Grenoble cedex 09, France.5Recherche épistémologiques et historiques sur les sciences exactes et les institutions scientifiques (REHSEIS), UMR 7596, Université Paris Diderot, Paris VII, 5 rue Thomas Mann, 75205 Paris Cedex 13, France 6 University Paris Descartes, 12 rue de l ’école de médecine,
75005 Paris, France.
Authors ’ contributions
AT collected the data and wrote the manuscript; MGO contributed to the design of the study and wrote the manuscript JFT contributed to the design of the study, did the statistical analysis with responsibility for integrity
of the data and the accuracy of the data analysis, and contributed to the final revision of the manuscript for important intellectual content AF did the statistical analysis with responsibility for integrity of the data and the accuracy of the data analysis AL contributed to the design of the study FP,
VW, JC, CB, and BM contributed to the final revision of the manuscript for important intellectual content All the authors read and approved the final manuscript.
Competing interests The authors declare that they have no competing interests.
Received: 29 June 2009 Revised: 30 November 2009 Accepted: 8 January 2010 Published: 8 January 2010 References
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doi:10.1186/cc8231 Cite this article as: Tabah et al.: Quality of life in patients aged 80 or over after ICU discharge Critical Care 2010 14:R2.
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